8 Reasons to Support the “Separate Benefit” Effort

There is danger in being labeled something you’re not — witness the
9.5-percent Medicare funding cut to the complex rehab power category
after it was carved out of future Medicare competitive bidding programs.

The current effort to secure a separate benefit for complex rehab technology
seeks in essence to more accurately identify and define both the types of equipment
used by severely involved seating & mobility clients, and the clinicians and
suppliers conducting the evaluations, fittings, fabrications, adjustments, client
training, and service/repair.

Our new Liberating Complex Rehab column will follow this effort —
one funded by AAHomecare, NCART, NRRTS and RESNA, and supported by
professionals from multiple disciplines (the Clinician Task Force is also lending
support). The column kicks off with Don Clayback, executive director of NCART
and chair of the separate benefit category steering committee made up of
professionals from multiple disciplines. Clayback offers his insight into why
the separate benefit category is needed… and why it deserves the industry’s
support. — L. Watanabe

#1: It’s time to stop comparing apples to oranges.

It’s an old, but entirely true argument: Complex rehab technology is different
than DME.

“The big picture is that complex rehab technology is a small segment of the
home medical equipment marketplace, and it is used by people who have in the
majority of the cases very significant disabilities,” Clayback says. “That’s why
they need this kind of equipment.”

Complex rehab is currently considered merely a type or form of DME, which
means its unique factors are often overlooked or not understood. Case in point:
After intensive lobbying and education efforts from the industry, complex rehab
power chairs and accessories were deemed inappropriate for Medicare competitive
bidding and were thus carved out of future programs. Yet, when it was
time to “pay for” a July 2008 postponement of the program, complex power
was included in the 9.5-percent funding cut along with the rest of the product
categories involved in the failed Round 1.

“What we see happening over the last few years,” Clayback says, “is
because there’s really a lack of understanding of what’s involved in this from
a payor perspective or a policy-maker perspective, there’s not the necessary
appreciation of the complexity of the products, the service component
of the delivery model and the costs that are incurred in that process. There’s
not enough awareness of that, so consequently — whether it’s coverage
changes or cutbacks or competitive bidding discussions — these products get
included in there, and really they’re not appropriate based on those dimensions
I mentioned.”

So if complex rehab technology is not DME, what is a good comparison?
Possibly orthotics and prosthetics (O&P), Clayback says, “at least to communicate
what we’re trying to accomplish.” He points out that O&P is “a separate
category within the DME benefit. Orthotics and prosthetics are treated differently
because they’re individual to the user of the equipment; they require evaluation,
assembly and fitting; and they require ongoing support.”

#2: This lack of distinction is hurting complex rehab
providers and consumers.

It’s easy for payors, referral sources, consumers and other stakeholders to
contend that the separate benefit is largely about increasing funding for
complex rehab. But the fact is that defining complex rehab as a slice of the
larger DME pie ultimately hurts consumers. “When we see coverage changes
or coverage limitations or when we see cutbacks, that’s eroding access to this
technology,” Clayback says.

“From a supplier perspective, I think it’s well recognized that this segment
isn’t a real attractive segment from a business perspective because it’s very
service intensive, the profit margins are low, and the paperwork requirements
are significant. From a pure business perspective, there’s a lot of challenges,
which means there’s less companies that are remaining in this business. As
those companies decrease, the patient access decreases. As those companies
are forced to undergo ongoing reductions, they have to limit either product
choice or limit services. They might not be able to continue to provide them
under continued rate reductions.”

So, sure — providers’ businesses are being hurt. But ultimately, having
fewer complex rehab businesses in existence will hurt the consumers who
need the technology and all the expertise and service that goes along with
it. Referral sources will also feel the frustration, if they have fewer qualified
complex rehab professionals to call upon.

When it comes to the connection between funding problems and accessibility
problems, Clayback explains, “I would say there’s a straight line — it’s
not a dotted line, it’s not even a long line. If there is a reimbursement problem,
that translates into an access problem. Or at least on the surface, immediately
the access (question) should come up.

“When you look at complex rehab technology, we’ve done studies through
NCART and there’s a variety of information that’s available. When you look at
other segments in the market, the number of companies that provide complex
rehab technology is very small, and that number is decreasing. So I can show
you all kinds of financial reports and fl ow charts and all the steps that are
involved, but this is a very difficult market to operate in, and I don’t think
there’s any better evidence than to say, ‘Look at the few companies that are still
operating in this business.’”

#3: This effort means no disrespect to DME.

Establishing a separate category for complex rehab isn’t a matter of having no respect for the existing DME benefit, but rather a matter of making sure
complex rehab is defined and understood as accurately as possible.

“There definitely is a place for durable medical equipment,” Clayback
says. “There’s definitely a place for respiratory equipment, so I think those
are well-recognized product categories. What we’re saying is that when you
start making decisions on coverage policy, payments, whatever, having these
specialized (complex rehab) products lumped in with other categories presents
some real access problems.”

#4: Complex rehab technology would finally be clearly
defined.

Up until now, complex rehab technology has too often been defined in the eye
of the beholder. Yes, Medicare made some inroads in separating consumer and
complex rehab power chairs, but overall, it’s still an incomplete, overlapping
and somewhat vague definition. For example, skin-protection and positioning
wheelchair cushions were part of the recent Round 1 rebid as part of a category
that Medicare calls Complex Rehabilitative Power Wheelchairs & Related
Accessories — Group 2.

But with the new benefit category would come, finally, very specific
definitions.

“We have clearly defined what complex rehab is,” Clayback says. “First, we
started with more of a broad definition. We have crafted the definition so it
isn’t just restricted to seating & mobility.”

In brief, Clayback says complex rehab would be defined as “an item that’s
medically necessary, that’s configured to the individual and requires a combination
of specific activities: evaluation, assembly, fitting, training, ongoing
support.” The definition goes on to list the diagnoses of patients who typically
use this type of equipment.

“Here’s the products, and here’s the people that use it,” Clayback says.

A more-detailed, two-page working definition includes what Clayback
calls the “four Ps — the products that we’re talking about, the people who
use it, the process that’s involved, and the professionals that are part of the
delivery model.” The initial focus is on seating & mobility, plus “other adaptive
equipment — standers, gait-trainers, other kinds of specialized equipment
that fall under that definition.” But Clayback adds, “Speech-generating
devices and other assistive communications devices would potentially fall
under that. We’ve had some initial discussion with those groups, and they’re
interested in this. They may become part of it or look to be involved down the
road at some point.”

To identify the specific products that meet this new definition, Clayback
says, “We’ve taken specific HCPCS codes — about 130 of them — that are
either strictly complex rehab, or a significant part of that product code is
complex rehab. One of the things we’d like to fix is for certain codes there’s
an overlap: You have complex rehab products and standard mobility products.
They both have a purpose and they both have a benefit, but for these
specific HCPCS codes, you have to be an accredited complex rehab provider
to provide them.”

#5: A seating & mobility client’s world should be made
up of far more than four walls and a roof.

Once upon a time, the phrase “in the home” was used to distinguish durable
medical equipment used in a Medicare beneficiary’s home from equipment
used in a hospital or healthcare facility setting.

But that was a long time ago, and somewhere along the way, “in the home”
morphed into a Centers for Medicare & Medicaid Services (CMS) restriction,
one that perhaps inadvertently, but very effectively limited the definition of a
Medicare beneficiary’s living spaces.

“We feel that, inappropriately, CMS interprets some of the language in
the Social Security Act that says equipment is only covered in the home,”
Clayback says. “We’re looking at eliminating that relative to complex rehab
technology.

“If someone needs a power wheelchair, they should be able to access the
necessary equipment, not just for their home needs, but also to get out into
the community for their medical needs, social needs, educational, work and
other needs. And really, our stated objective for this category is to improve
and protect access for people with disabilities that need these products.”

Long the bane of complex rehab consumers, the in-the-home restriction
might help stir consumer interest in the industry fight to establish a separate
benefit category.

“The consumer is really the focus,” Clayback says, “and we’ve had some
very productive discussions. I think this gives us the opportunity to have a
stronger connection with consumer groups and have some frank discussions.”
(Example: Paul Tobin, president of United Spinal Association, is a separate
benefit category steering committee member.)

“If I’m a consumer…I want a company that’s got a good selection of products,
that’s going to give me good customer service, and is going to be around
if I need some sort of support,” he notes. “I think we all realize that for those
companies to exist, the business environment has to be such that there’s appropriate
coverage policies and payment rates.”

And speaking of payment rates: Next month, in part two of this column, we
discuss three more reasons to support the separate benefit effort, including the
role that funding will play, the need for new complex rehab technology provider
standards, and the project’s various work groups, which are tackling this effort
from several critical angles. Plus, we’ll share ways that you can get plugged in
and help drive this meaningful effort.

This article originally appeared in the September 2010 issue of Mobility Management.